Surgical resection of primary intracardiac sarcomas and outcomes: A review of case reports over 20 years

Objective

A quarter of all cardiac tumors are malignant, and most (~ 95%) are sarcomas. It is the most aggressive malignant cardiac tumor carrying the worst prognosis. Tumor involvement with the vital intracardiac structures makes it difficult for complete surgical resection. We aimed to study the role of complete surgical resection and its importance in long-term outcomes.

Methods

We analyzed published literature from 2002 to 2022 using PubMed. Cases reported adult, intracardiac sarcomas, and received surgical resections were included. We reviewed 132 published case reports, including and analyzed the following variables: demographics, clinical presentations, diagnostic imaging modality, the extent of surgical resection, pathological diagnosis, tumor location, postoperative chemo-radiation therapy, and follow-up (including re-operation, local and distant recurrence).

Results

A total of 135 patients are included from 132 articles. The mean age was 46.69 (18-86) and 76 patients were females. The main complaints were dyspnea (70%) and chest pain (32%). Performed investigations were transthoracic echocardiography (TTE) in 114/135 (84%), computer tomography (CT) scan 89/135 (66%), trans-esophageal echocardiography (TOE) 22%, and cardiac magnetic resonance imaging (MRI) 29%. The most common location was the atrium (left 46%, right 30%). Complete surgical resection was performed in 91 cases (67%), and frozen section was performed in 62 patients (43 positives). Incomplete resections were in 42 cases. Patients who underwent complete surgical resection had mean survival of 14.58 months and median of 10.5 months, compared to incomplete resection patients with 9.12 months and 6.5 months respectively.

Conclusion

Our review shows complete surgical resection results in better short- and long-term outcomes in intracardiac sarcoma patients. Furthermore, combining chemo-radiotherapy has additional benefits towards long-term survival.

Primary undifferentiated high-grade pleomorphic cardiac sarcoma in the left atrium with atypical presentation

A woman in her 60s had 4 months of malaise, fatigue, dyspnoea, night sweats and grade 3 clubbing. She had a pansystolic murmur and signs of congestive heart failure. Multimodal imaging with a transthoracic echocardiogram, transoesophageal echocardiogram and CT was carried out to diagnose and reconstruct the mass for surgical planning. A 2×2.8 cm circular dense mass was found in the left atrium with vegetations on the mitral valve. Positron emission tomography and cardiac MRI confirmed the mass's hypermetabolic activity and malignant features. Mitral valve replacement and surgical resection were performed. She was diagnosed with grade 3 undifferentiated cardiac sarcoma and referred to the sarcoma multidisciplinary team for further management given sarcoma's rarity and complexity. The poor prognosis of sarcoma was evident as her symptoms recurred 2 months postoperatively.

If I had a hammer

We present the case of a 64-year-old man who was referred to our service after sustaining a self-inflicted nail-gun injury to his chest. He received three nails penetrated into his chest. Computer tomography revealed no massive haemorrhage or damage to major vessels. He underwent an emergency sternotomy, two nails caused pericardial perforation and myocardial injury were noted easily and removed easily via sternotomy. Myocardial injury showed a trajectory near the junction of the left anterior descending artery and the diagonal artery with no significant bleeding appreciated. The third nail was deep in the lung parenchyma at the hilum. A pacemaker magnet was used to locate the third nail, which was subsequently removed. Our case demonstrates the use of magnets in emergency surgery, to locate and remove metallic foreign bodies.

Anomalous right upper lobe venous drainage

Lung resections are usually not associated with significant bleeding, but can be fatal, especially in cases of video-assisted thoracoscopic surgery (VATS). Anomalous vascular structures could be a major reason for unexpected bleeding in such surgeries. We present a case of an aberrant upper lobe pulmonary vein that was encountered posterior to the right upper lobe bronchus during a right upper lobectomy via thoracotomy. The anomalous pulmonary vein was identified preoperatively on a computed tomography (CT) scan and hence was looked for before dividing the bronchus. Many centres are adopting the VATS approach for performing lung resections. If an anomalous vein is present posterior to the bronchus, it might be in a blind spot and could be damaged inadvertently, leading to profuse and potentially fatal bleeding. We conclude that the identification of anomalous vascular structures prior to surgery with the help of CT helps in avoiding adverse outcomes.

Infiltrating angiolipoma of the chest wall: a rare clinical entity

Angiolipoma is a rare variant of lipoma. Infiltrating chest wall angiolipoma usually presents as painful subcutaneous lesions. There are only a handful of cases reported in the literature. Malignancy is suspected in the differential diagnosis, and hence a tissue diagnosis is needed to rule out an underlying malignancy. Symptomatic infiltrating angiolipoma warrants surgical excision. We report a case of an infiltrating angiolipoma of the chest wall, which was successfully treated with surgical excision.

A case of lung volume reduction surgery with decortication for a septic patient in respiratory failure

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Decortication and lung volume reduction surgery are both major operations and each has its independent risk of morbidity and mortality.

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Bullae can produce signs and radiologic appearances of pneumothorax and it is important to differentiate them before treatment. The differentiation between giant bulla and pneumothorax can be very difficult and often leads to inaccurate diagnosis and management.

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The NETT trial showed that patients most likely to benefit from lung volume reduction surgery have heterogeneously distributed emphysema involving the upper lung zones predominantly.

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Our case demonstrates the feasibility of achieving an excellent overall outcome with a combination of complex procedures.

Introduction

Decortication and lung volume reduction surgery are both major operations and each has its independent risk of morbidity and mortality.

Case report

We present the case of a 41 year old gentleman with left sided empyema and giant bullae of the upper lobe with an active air leak that was transferred to our tertiary referral centre for further management. We performed emergency left thoracotomy, decorticated the left lower lobe with extensive lung volume reduction surgery of the upper lobe. Patient’s respiratory status significantly improved along with excellent radiological results.

Conclusion

Our case demonstrates that a combination of complex procedures is feasible with excellent outcomes.

Kikuchi-Fujimoto disease: an unusual cause of neck swelling in pregnancy

Kikuchi-Fujimoto disease (KFD) is an unusual cause of lymphadenopathy and fever. Pregnancy associated with KFD presents as a diagnostic dilemma for clinicians. The diagnosis can be confirmed with invasive biopsies or non-invasive gene analysis. We report a case of a 24-year-old woman at 18 weeks' gestation with a neck lump and histologically confirmed KFD.

Thoracic vertebral osteomyelitis: an unusual complication of Crohn's disease

Vertebral osteomyelitis complicating Crohn's disease is a rare occurrence and mostly occurred in patients with Crohn's disease complicated by an abscess or fistulising disease. We report a case of thoracic vertebral osteomyelitis, occurring in a refractory Crohn's disease without contiguous abscess or fistula with the bowel.